Rectovaginal tears occur after sex toys insertion, rape, and accidents1. They may cause severe life-threatening bleeding2. Rectovaginal tears after consensual sexual intercourse, are extremely rare3. In most cases, a sphincter trauma is present. We report a case with a two cm laceration to the posterior vaginal and anterior rectal wall, sparing the sphincters.

A 22-year-old nulliparous woman presented with acute vaginal bleeding and severe pain after sexual intercourse with her male partner. The couple reported no use of sex toys or foreign bodies during sexual intercourse. Vaginal examination revealed a two cm laceration of the vaginal wall, communicating directly with the anterior rectal wall. No injury of the anal sphincters was recognized. She was informed about her condition and the available treatment options. Under general anesthesia, she underwent an open diverting loop sigmoidostomy. No imaging was performed before operation as it was not considered necessary by surgeons. Continuous suture technique in two-layers (rectal - vaginal wall) was utilized for the repair of the vaginal tear with 1/0 Vicryl Rapide suture (Ethicon Inc., Somerville, NJ, USA). The operation lasted about 90 minutes. During her hospitalization she was administered intravenous Cefoxitime and Metronidazole for two days, and then per os for another 7 days. Her postoperative course was uneventful, and she was discharged the fourth postoperative day. Six weeks later, on her follow-up examination, the vaginal tear had completely healed and reversal of sigmoidostomy was performed at that time.

Sexual intercourse is the major cause of vaginal injury, apart from a vaginal delivery. According to literature risk factors for severe genital trauma, either after consensual or nonconsensual sexual intercourse, are the vaginal atrophy and anatomical changes due to menopause2,3. First sexual experience, nulliparity, rape, and young age are also risk factors for coital injuries during intercourse2. The mechanism is not fully known, but vigorous penetration and congenital weakness of the posterior vaginal wall have been regarding as possible reasons. During anal penetration, the posterior vaginal wall may be injured leading to rectovaginal tear. Simultaneous penetration to vagina and anus is another cause of high pressure to the posterior vaginal wall. Minimal vaginal bleeding very often leads to a delayed presentation and diagnosis while severe vaginal bleeding is reported to have led to hemorrhagic shock3. Prompt repair of the tear provides better healing and less postoperative complications4.

A high index of suspicion is required to define the possibility of nonconsensual intercourse, even if the patient denies it. Patients many times deny nonconsensual sex, because of its social impact. On the other hand, there are situations when they invoke false nonconsensual intercourse, to achieve money avail. So, this rare incident is a challenge for the attending physician due to its social and legal dimensions.